Online Counseling Services Request

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Please complete this brief interest form and a Care Coordinator will reach out to you within two business days.

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Name (First & Last) *

If your preferred first and/or last name is different from your legal first and/or last name, please list both in the area provided.

Phone Number *

Email Address: *

If you think your District/Employer/Community Organization partners with HearYou.org, please list below: *

If you are unsure, please list N/A

Are services required in a language other than English? If yes, please enter the language required below:

I would like to be connected with a counselor who works with:
*

Adults

Children (5 to 11 years old with parent/guardian consent)

Adolescents (12 to 17 years old with parent/guardian consent)

Couples

Families

I would like help with: *

Select all that apply

Anxiety/Worry

Coping with a medical illness (me or a loved one)

Grief and loss

LGBTQ+ support

Major life transition

Managing strong emotions

Parenting

Relationship Issues

Sadness

Traumatic Experience(s)

I prefer to share with my counselor

Other:

Required

What are your preferred times to meet with a HearYou.org Counselor? *

Please select all that apply

Weekday Mornings

Weekday Afternoons

Weekday Evenings

Saturday

Required

Please tell us how you heard about HearYou.org. *

Communication from my District/ Employer/ Community Partner

Coworker/Friend

Website

Social Media

Magazine

Conference/Event

Fyler

Other:

Required

I agree to the terms & conditions of HearYou.org.
*

Yes

Required

Thank you for taking the time to let us know about you.

Our Care Coordinator will get back to you within two business days.

If you are experiencing a medical or psychiatric emergency - don’t use this site. Call 911. If you need to speak with someone immediately call or text The Lifeline at 988.

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